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. 2022 May 4;7(7):770–772. doi: 10.1001/jamacardio.2022.0775

Trends in Transcatheter vs Surgical Mitral Valve Repair Among Medicare Beneficiaries, 2012 to 2019

Michael N Young 1, Stephen Kearing 2, Mazen A Albaghdadi 3, Azeem Latib 4, Alexander Iribarne 2,5,
PMCID: PMC9069336  PMID: 35507335

Abstract

This cross-sectional study of Medicare data from 2012 to 2019 assesses national trends in the use of mitral transcatheter edge-to-edge repair relative to surgical mitral valve repair.


Mitral transcatheter edge-to-edge repair (TEER) has emerged as an alternative to surgical mitral valve repair (SMVR) in patients with a prohibitive surgical risk or advanced heart failure with severe, symptomatic mitral regurgitation (MR).1,2 Characterizing the geographic and demographic dispersion of TEER and SMVR is important for understanding access to care and the populations served by these therapies. As there is a clear learning curve with TEER, understanding the growth in its use is of direct relevance to hospitals, physicians, and patients.3,4,5 In this cross-sectional analysis, we characterize national trends in the use of TEER relative to SMVR in a large Medicare population.

Methods

We queried the Medicare Provider Analysis and Review (MedPAR) File from 2012 to 2019 for all fee-for-service Medicare beneficiaries undergoing SMVR (n = 34 375) and TEER (n = 16 931). We used International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes for SMVR and TEER.

The ratio of TEER-to-SMVR procedural counts was stratified according to geographical location and year, as well as age, sex, and race and ethnicity. All analyses were performed using SAS software, version 9.4 (SAS Institute Inc).

Results

The Table shows the trends in the use of TEER vs SMVR stratified according to patient demographic characteristics. There was continued growth in TEER use throughout the study period, while SMVR use remained comparatively constant (Figure, A). In 2012, the rate of TEER use was 0.76 per 100 000 beneficiaries and increased to 17.95 by 2019 (P < .001). In contrast, SMVR use decreased from 16.06 to 13.58 per 100 000 (P = .04). The annualized ratio of TEER to SMVR increased from 0.05 to 1.32 (P < .001) (Figure, B). The number of hospitals performing TEER grew from 91 in 2013 to 396 in 2019, and the median distance to care decreased from 44.2 miles in 2012 to 19.0 in 2019 (P = .003); the number of hospitals performing SMVR remained consistent between 2012 and 2019 (730 and 721), and the median distance to care increased from 17.2 miles in 2012 to 21.7 in 2019 (P = .001).

Table. Biennial Ratios of Transcatheter Edge-to-Edge Repair to Surgical Mitral Valve Repair.

Characteristic 2013 2015 2017 2019 P value
TEER SMVR Ratio TEER SMVR Ratio TEER SMVR Ratio TEER SMVR Ratio
Total 228 4412 0.05 1592 4233 0.38 3024 4629 0.65 5111 3867 1.32 <.001a
Age, y
65-74 67 2327 0.03 309 2316 0.13 607 2570 0.24 1146 2294 0.50 <.001b
75-84 95 1801 0.05 644 1680 0.38 1231 1878 0.66 2248 1472 1.53
≥85 66 284 0.23 639 237 2.70 1186 181 6.55 1717 101 17.00
Sex
Male 123 2462 0.05 830 2377 0.35 1550 2685 0.58 2707 2323 1.17 <.001b
Female 105 1950 0.05 762 1856 0.41 1474 1944 0.76 2404 1544 1.56
Race and ethnicity
White, Non-Hispanic 208 4024 0.05 1469 3877 0.38 2712 4184 0.65 4538 3455 1.31 .02b
Otherc 20 388 0.05 123 356 0.35 312 445 0.70 573 412 1.39
Geographic location
South 87 1680 0.05 588 1592 0.37 1146 1743 0.66 1977 1331 1.49 <.001b
Midwest 41 1111 0.04 361 1019 0.35 581 1174 0.49 988 1032 0.96
Northeast 45 870 0.05 251 922 0.27 562 954 0.59 903 784 1.15
West 55 751 0.07 392 700 0.56 735 758 0.97 1243 720 1.73

Abbreviations: SMVR, surgical mitral valve repair; TEER, transcatheter edge-to-edge repair.

a

Cochran-Armitage trend test of TEER-to-SMVR ratios.

b

χ2 Test of TEER-to-SMVR ratios associated with patient characteristics.

c

Other included Asian or Pacific Islander, American Indian or Alaska Native, Black, Hispanic, and unknown. Specific numbers for these categories are unavailable because of Centers for Medicare & Medicaid reporting policies.6

Figure. Use of Transcatheter Edge-to-Edge Repair (TEER) vs Surgical Mitral Valve Repair (SMVR), 2012-2019.

Figure.

Food and Drug Administration (FDA) approval of TEER for primary mitral repair occurred in 2013. FDA approval of TEER for secondary mitral repair occurred in 2019.

Discussion

We observed a significant increase in the use of TEER relative to use of SMVR among Medicare beneficiaries over the course of 8 years. The growth in TEER closely follows approval of the MitraClip (Abbott), with an initial rise in 2013 after its approval for primary MR and continued growth in 2019 after its approval for secondary MR.2

During the study period, SMVR use remained stable, while TEER continued to grow. This phenomenon has also been observed for transcatheter aortic valve replacement.7 Notably, we found that use of TEER surpassed that of SMVR by mid-2018, suggesting TEER has become a new option for patients who might not have been candidates for surgery, such as those at high surgical risk or with left ventricular dysfunction and secondary MR in whom medical therapy has failed.

We also found significant geographical dispersion of TEER and hospitals performing TEER throughout the US and observed variation in the use of TEER vs SMVR among demographic subgroups, with use of both TEER or SMVR being lower among female patients and members of racial or ethnic minority groups. These disparities could be associated with inherent differences in epidemiological factors as well as other social determinants of health or treatment biases.

This analysis is limited by the exclusion of non-Medicare beneficiaries, as well as the inability to differentiate between the relative use of TEER and SMVR for primary vs secondary MR. We also did not include data on surgical or transcatheter mitral valve replacement. Nevertheless, understanding the continued growth and dispersion of TEER and potential disparities in surgical and transcatheter mitral valve therapies have important clinical and regulatory implications.

References

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